<html><head><title>Grievance and Appeals Data Analyst - San Jose, CA 95119</title></head>
<body><h2>Grievance and Appeals Data Analyst - San Jose, CA 95119</h2>
<p><b>FLSA Status:</b> Exempt</p>
<p><b>Department:</b> Grievance and Appeals</p>
<p><b>Reports To:</b> Director, Grievance and Appeals Operations</p>
<p><b>Salary:</b> $67,942- $101,913</p><br/>
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<p><b>Employee Unit:</b> Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521.</p><br/>
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<p><b>GENERAL DESCRIPTION OF POSITION</b></p>
<p>The Grievance and Appeals Data Analyst is responsible for the development of monthly, quarterly, and annual reporting to regulators in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business. The Grievance and Appeals Data Analyst consults with IT regarding the review of business requirements, functional specifications and internal operations processes and acts as the subject matter expert (SME) in the validation of software and reports. The Grievance and Appeals Analyst also provides reports for tracking and trending purposes in order to identify interventions to improve service and reduce grievances and appeals.</p><br/>
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<p><b>ESSENTIAL DUTIES AND RESPONSIBILITIES</b></p>
<p>To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.</p>
<ul><li>Develop daily, weekly, monthly, and annual regulatory and operations reports for submission to the Centers for Medicare and Medicaid Services (CMS), the Department of Health Care Management (DMHC), the Department of Health Care Services (DHCS), and internal units. Accurately interprets and implements federal and state administrative regulations in order to appropriately define reports and interface with the IT Department</li><li>Build and maintain internal grievance and appeals databases or system of record in an SQL environment in consultation with the IT Department. Coordinate with the Grievance and Appeals Coordinators or designee(s) to accurately adjust values in the system of record as needed</li><li>Act as SME for the grievance and appeals system of record, including creation and maintenance of business requirements</li><li>Coordinate with IT to enhance data and system needs for the department, including periodic system analysis and implementation of required enhancements</li><li>Manage projects related to grievance and appeals reporting and/or data, including planning and coordinating of stakeholder project team meetings, identifying and assigning action items and sending periodic communication to the project team and stakeholders, escalating risks as needed</li><li>Coordinate with internal and external customers to obtain relevant grievance and appeals data</li><li>Coordinate activities for regulatory audits and internal mock audits, including data source submission, reporting policy development or maintenance and scheduling meetings to ensure reporting requirements are met</li><li>Conduct grievance and appeals data validation and root cause analysis on findings</li><li>Perform other related duties as required or assigned</li><br/>
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<p></p><p><b>REQUIREMENTS – Required (R) Desired (D)</b></p>
<p>The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.</p>
<ul><li>Bachelor’s Degree in Business Analytics, Computer Science, Health Information Technology, or related field, or equivalent experience, training or coursework. (R)</li><li>Knowledge of and experience with SQL, data analysis, report development/generation, and database management/maintenance. (R)</li><li>Ability to consistently meet reporting timeframes according to regulatory requirements. (R)</li><li>Ability to analyze and interpret data to identify trends. (R)</li><li>Knowledge of health plan operations. (D)</li><li>Ability to interpret and translate regulatory requirements, technical specifications and business needs to reports required for regulatory purposes and actionable reports. (D)</li><li>Knowledge of project management standards and functions. (D)</li><li>Work weekends and company holidays as needed based on business regulatory requirements (R)</li><li>Ability to conduct all necessary research, root analysis and trends to accurately identify complex issues. (R)</li><li>Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the Grievance and Appeals Department operations as dictated by business needs (R)</li><li>Ability to consistently meet grievance and appeals accuracy and timeline requirements by achieving regulatory standards. (R)</li><li>Working knowledge of and the ability to efficiently operate all applicable computer applications and/or software including a working knowledge of computer applications such as Outlook, Word, Access and Excel. (R)</li><li>Ability to use keyboard with moderate speed and a high level of accuracy. (R)</li><li>Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, Members, Providers and outside entities over the telephone, in person or in writing. (R)</li><li>Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)</li><li>Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)</li><li>Ability to maintain confidentiality. (R)</li><li>Ability to comply with all SCFHP policies and procedures. (R)</li><br/>
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<p></p><p><b>WORKING CONDITIONS
</b></p><p>Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.</p><br/>
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<p><b>EOE</b></p></body>
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